<h4>Contact Information</h4>
<hr>

<div class="form-group">
  <label class="control-label col-md-2">Full name</label>
  <div class="col-md-10">
    <input class="form-control"></input>
  </div>
</div>

<div class="form-group">
  <label class="control-label col-md-2">Country/Region</label>
  <div class="col-md-10">
    <select class="form-control">
      <option></option>
    </select>
  </div>
</div>

<div class="form-group">
  <label class="control-label col-md-2">Address</label>
  <div class="col-md-10">
    <input class="form-control"></input>
    <input class="form-control"></input>
  </div>
</div>

<div class="form-group">
  <label class="control-label col-md-2">City</label>
  <div class="col-md-10">
    <input class="form-control"></input>
  </div>
</div>

<div class="form-group">
  <label class="control-label col-md-2">State/Province</label>
  <div class="col-md-10">
    <select class="form-control">
      <option></option>
    </select>
  </div>
</div>

<div class="form-group">
  <label class="control-label col-md-2">Email address</label>
  <div class="col-md-10">
    <input class="form-control"></input>
  </div>
</div>

<div class="form-group">
  <label class="control-label col-md-2">Phone</label>
  <div class="col-md-10">
    <input class="form-control">
  </div>
</div>